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To be completed by patient who are undergoing Visa Medical or Occupational Health checks

Page 1 of 4

  1. Title*
    Please select your title
  2. Full Name*
    Please enter your full name
  3. Date of Birth*
    / / Select your date of birth
  4. Gender*
    Select your gender
  5. Full Address*
    Enter your full address
  6. Postcode*
    Please enter your postcode
  7. Telephone
    Please enter your landline number
  8. Mobile*
    Please enter mobile number
  9. Email*
    Please enter your email address
  10. Where did you hear about us?
  1. What is your Occupation?
  2. Do you Smoke?*
    Please select an option
  3. If YES, how many per day?
  4. If NO, have you ever smoked?*
    Please select an option
  5. If YES, how many per day?
  6. Do you drink alcohol?*
    Please select an option
  7. If YES, how many units per week?
  8. How long have you been drinking this amount?
  9. Do you look after someone or does someone look after you?*
    Please select an option
  10. If Yes, please provide details
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  1. Previous Medical History
  2. Are you currently being treated for any ongoing medical problems?*
    Please select an option
  3. If Yes, which ones
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  4. Are you currently taking any regular medication?*
    Please select an option
  5. If Yes, which
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  6. Are you allergic to any medicines?*
    Please select an option
  7. If Yes, which ones
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  8. GP Details
  9. The name of your GP
    Please enter your GP name
  10. GP Address
    Enter your full address
  11. Telephone
    Please enter your landline number
  12. Next of Kin
  13. Name
    Please enter your next of kin name
  14. Relationship to you
    Enter your relationship with this person
  15. Address
    Enter your full address
  16. Telephone
    Enter this persons contact number
  1. If you have any tests conducted at Edgbaston Private Medical Practice how would you like to be informed of the results?
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  2. Do you give permission for Edgbaston Private Medical Practice to write to your GP about your attendance.*
    Please select an option
  3. Do you give permission for Independent Body authorised by ourselves to contact you to assess our level of service.*
    Please select an option
  4. Do you give permission for the Edgbaston Private Medical Practice to send details of up to date services via email.*
    Please select an option
  5. The information I have given is to the best of my knowledge, correct. I have not knowingly withheld any relevant information medical or surgical information.

    I authorise Edgbaston Private Medical Practice to provide my employer with a copy of the medical report/certificate generated from an examination/assessment today.*
    Please check the form and agree to the disclaimer

Edgbaston Private Medical Practice is a trading name of Lister Medical Group Ltd, Registered Office: 44 George Road, Birmingham, B15 1PL, UK Company Reg No.: 09594751